Acadia Center For Nursing And Rehabilitation

Based on observations, record review, and interviews, during the recertification survey initiated on 9/11/2024 and completed on 9/18/2024, the facility did not ensure that food was stored in accordance with professional standards for food service safety. This was identified during the Kitchen Task. Specifically, expired and opened containers of food were observed in the refrigerator; The freezer was observed with frozen food products out of their original packaging with no label or date. Additionally, stored dry goods were unlabeled and undated in the basement dry storage area.
The finding is:
An undated facility policy titled Food Storage documented foods received shall be properly stored to maintain high quality and sanitary conditions. Items may be utilized until the date of expiration, based on the production date and item shelf life. Dry bulk foods such as flour, rice, or pasta, once opened, shall be stored in a plastic container with a cover. All items should be dated and labeled. All goods will be rotated properly using the first in, first out method.
A kitchen tour was conducted with the Food Service Director on 9/11/2024 at 10:15 AM. The refrigerator section of the combination walk-in refrigerator/freezer was observed with three expired, open containers of cottage cheese. Two containers were observed with an expiration date of 8/19/2024 and one container with an expiration date of 8/12/2024. The freezer section of the combination walk-in refrigerator/freezer was observed with three packages of French toast sticks which were out of the original packaging and had no label or date. Additionally, six bags of frozen broccoli that were out of the original packaging were observed without a date.
The basement dry storage area and a basement walk-in combination refrigerator/freezer were observed with the Food Service Director on 9/11/2024 at 10:29 AM. In the dry storage area, six bags of cake mix were observed that were removed from their original packaging and had no date. In the refrigerator section of the walk-in combination refrigerator/freezer, there were unlabeled and undated packages of chicken, three bags of shredded pizza cheese, and five bags of shredded cheddar cheese. In the freezer section of the walk-in refrigerator/freezer, there was an open bag of pancakes and an unidentified bag of food without a label and date.
The Food Service Director was interviewed on 9/18/2024 at 10:50 AM and stated that the containers of expired cottage cheese were left in the refrigerator because the dietary aides did not rotate or take out the old containers. The Food Service Director stated that the dietary aides and the cooks should read the expiration dates and discard the outdated items. The Food Service Director stated the person who placed the chicken in the basement refrigerator/freezer should have labeled and dated the packages or the tray they were stored on. The Food Service Director stated the dietary aide assigned to the storeroom or any person who takes something out of the original packaging is responsible for labeling and dating the food items. The Food Service Director stated it is important for food items to be labeled and dated so that kitchen staff know what the food item is and when to prepare the food item. The Food Service Director stated food should not be left open in the freezer because the food item can get freezer burn if not properly stored. The Food Service Director stated it is important to check the expiration dates of food to ensure that the food is not spoiled.
10 NYCRR 415.14(h)

Based on observations, record review, and interviews during the Recertification Survey initiated on 9/11/2024 and completed on 9/18/2024, the facility did not ensure medications were properly stored in medication carts. This was identified for two (Unit A and Unit C) of four units reviewed during the Medication Storage Task. Specifically, loose unidentifiable medications were observed in medication carts in Unit A and Unit C; residents' hearing aids, hearing aid batteries, and nail clippers were stored in medication carts in Unit A and Unit C; and the Unit C Medication Storage Room refrigerator had a dried pink substance spilled on the refrigerator shelf.
The findings are:
The facility Medication cart policy, revised in March 2024, documented all medication carts will remain free from all non-medication items (i.e. hearing aids, nail clippers). The nursing staff is responsible for checking the medication cart for any loose medications every shift.
The Medication Rooms policy, revised in March 2024, documented all medication rooms will be maintained in a state of cleanliness and ensure the refrigerator is clean and the freezer is defrosted as per schedule.
The Blister Packs and Newly Opened Medications policy, revised in 1/2023, documented that nurses should initial and date the blister pack as the first dose of medication is administered. The new bottle of liquid medication or any Over The Counter/ House Stock medication should be dated when first opened.
Unit A Medication Cart #2 was observed on 9/12/2024 at 4:58 PM with Licensed Practical Nurse #3. There were three large nail clippers, hearing aids, and hearing aid batteries stored in the top drawer of the medication cart.
Licensed Practical Nurse #3 was interviewed immediately after the observation on 9/12/2024 and stated the nail clippers were used for clipping the diabetic residents' nails and that they should not have kept them in the medication cart. Licensed Practical Nurse #3 stated the medication cart should not be used to store items other than the medications, such as hearing aids and hearing aid batteries.
Unit A Medication Cart #1 was observed on 9/12/2024 at 5:04 PM with Licensed Practical Nurse #4. There were 18 unidentified loose medications, including capsules and tablets, observed on the base of the second drawer of the medication cart.
Licensed Practical Nurse #4 was interviewed immediately after the observation on 9/12/2024 and stated there should not be any unidentified loose pills in the cart. Licensed Practical Nurse #4 stated they did not know there were loose tablets and capsules in the medication cart before the observation.
The Unit C Medication Cart was observed on 9/12/2024 at 5:13 PM with Licensed Practical Nurse #5. There were 24 unidentified loose medications, including capsules and tablets noted on the base of the second drawer of the medication cart. There were two large nail clippers, hearing aids, and hearing aid batteries stored in the first drawer of the medication cart.
The Unit C Medication Storage Room was observed on 9/12/2024 at 5:15 PM with Licensed Practical Nurse #5. There was an opened and undated 12-ounce bottle of Geri Lanta (an antacid medication) on the shelf in the medication storage room. The medication storage room refrigerator was observed with a pink dried substance spilled at the bottom of the second shelf.
Licensed Practical Nurse #5 was interviewed immediately after the observation on 9/12/2024 and stated the pink residue in the refrigerator must be from a medication stored in the refrigerator. Licensed Practical Nurse #5 stated the nurses should have cleaned the refrigerator. Licensed Practical Nurse #5 stated they didn't know who opened the undated Geri Lanta and it should have been discarded after a month from when it was first opened. Licensed Practical Nurse #5 stated they should not have kept any items other than the medications in the treatment carts. Licensed Practical Nurse #5 stated they did not realize the medication cart had loose medications. Licensed Practical Nurse #5 stated all nurses should make sure there are no loose medications in the medication carts.
The Director of Nursing Services was interviewed on 9/18/2024 at 12:30 PM and stated it was not acceptable to have loose medications, nail clippers, and hearing aid batteries in the medication cart. The nail clippers and the hearing aid batteries should be stored in the treatment cart. The Director of Nursing Services stated the nurses should keep the medication carts and medication storage rooms clean. The Director of Nursing Services stated open medication bottles should be labeled to determine when to discard the medication.
10 NYCRR 415.18 (d)(e)(1-4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey initiated on 1/31/2023 and completed on 2/7/2023, the facility did not ensure that resident who need respiratory care, is provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan. This was identified for one (Resident #224) of two residents reviewed for oxygen. Specifically, Resident #224 had a Physician's order for continuous oxygen at two liters per minute via a nasal cannula (tubing used to deliver supplemental oxygen). On two separate occasions, the resident was observed not receiving oxygen therapy as prescribed by the resident's Physician.
The finding is:
The facility's Policy and Procedure for Physician's orders last updated on 1/5/2018 documented that the nursing staff must follow the orders of the Physician (MD)/Physician Assistant (PA)/Nurse Practitioner (NP), and if clarification is needed, the staff must communicate with the resident's MD/PA/NP.
Resident #224 was admitted with diagnoses that included COVID-19 infection, Hypertension, and Acute Cough. The admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 14 which indicated the resident had intact cognition. The resident had no behavioral symptoms and did not reject care. The resident was non-ambulatory and required extensive assistance of two staff members for transfers.
A Comprehensive Care Plan (CCP) for Oxygen Use dated 10/26/2022 documented the resident required supplemental oxygen due to episodes of shortness of breath related to a history of COVID-19 infection. Interventions included to check for the proper placement of oxygen tubing and to provide oxygen as ordered by the MD.
A Physician's order dated 12/4/2022 documented to administer oxygen via a nasal cannula (NC) at two liters per minute continuously every shift at 11:00 PM-7:00 AM, 3:00 PM-11:00 PM, and 7:00 AM-3:00 PM.
The Treatment Administration Record (TAR) dated 1/2023 documented oxygen therapy was administered continuously as per the physician's orders as indicated by staff signatures.
Resident #224 was observed on 1/31/2023 at 11:52 AM lying in bed awake and responsive to their name and greetings. The nasal cannula was observed laying on the bed away from the resident still attached to the concentrator while the concentrator was on. The resident was unable to explain why the tubing was laying on the bed.
Licensed Practical Nurse (LPN) #8, who cared for the resident on the 7:00 AM-3:00 PM shift on 1/31/2023, was made aware of the observation on 1/31/2023 at 11:53 AM. LPN #8 stated that Resident #224 is on continuous oxygen and sometimes removes their oxygen tubing; however, staff should monitor the resident to ensure that the oxygen tubing is in place. LPN #8 replaced the nasal cannula on the resident.
Resident #224 was observed on a second occasion on 2/1/2023 at 10:26 AM. Resident #224 was asleep in bed without the oxygen nasal cannula in place. The oxygen tubing was observed coiled and tucked under the oxygen concentrator handle and the oxygen concentrator was on.
LPN #7, who cared for the resident on 2/1/2023 during the 7:00 AM-3:00 PM shift, was interviewed on 2/1/2023 at 10:26 AM. LPN #7 stated that the resident sometimes removed their oxygen tubing; however, the resident could not have coiled the oxygen tubing and tucked the tubing under the oxygen concentrator handle. LPN #7 stated that they could not say who removed the resident's oxygen tubing. LPN #7 stated that the resident is on continuous oxygen as per the physician's orders and should have been wearing the nasal cannula.
Certified Nursing Assistant (CNA) #3 was interviewed on 2/7/2023 at 12:26 PM and stated that they were assigned to care for the resident on 1/31/2023 and 2/1/2023 and were responsible to ensure that the resident was wearing the nasal cannula to receive their oxygen. CNA #3 stated at times the resident removes their nasal cannula; however, the resident was not able to ambulate and therefore could not have coiled the oxygen tubing and tucked the tubing under the oxygen concentrator handle.
The Director of Nursing Service (DNS) was interviewed on 2/7/2023 at 12:40 PM and stated Resident #224 can be non-compliant with their oxygen therapy at times; however, the staff should be checking to ensure the resident was receiving continuous oxygen as per their Physician's orders.
Physician Assistant (PA) #2 was interviewed on 2/7/2023 at 3:21 PM and stated that they expected that staff should carry out the Physician's order as written and that the resident should have been wearing their nasal cannula and receiving supplemental oxygen as per the Physician's orders. PA #2 further stated that if the resident was identified to be removing the nasal cannula the staff should have monitored the resident to ensure the resident was receiving oxygen as ordered.
10NYCRR 415.12(k)(6)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews during the Recertification Survey initiated on 1/31/2023 and completed on 2/7/2023, the facility did not ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This was identified for one (Resident #64) of two residents reviewed for Pain Management. Specifically, during the medication administration observation task on 2/1/2023 for Resident #64, the resident complained of inadequate pain control to Licensed Practical Nurse (LPN) #2 medication nurse; however, there was no documented evidence that this was reported by the nurse to the resident's Physician until the next day (2/2/2023). Additionally, the resident's pain was not consistently assessed and monitored before and after administration of the pain medications to identify the effectiveness of the resident's pain management.
The finding is:
The facility's policy titled Pain Assessment and Management, revised 10/2015, documented the facility recognizes the right of every resident to be free of pain. The physician must be immediately notified if the resident has no relief from the medication and continues to have pain. Additional pain medication may be needed for breakthrough pain. For as-needed (PRN) medications, after every administration, the nurse evaluates the effectiveness of the medication. If the resident is still experiencing pain, the nurse notifies the physician and documents in the medical record.
Resident #64 was admitted with diagnoses including Idiopathic Peripheral Autonomic Neuropathy, Cellulitis of the Right and Left Lower Limbs, and Arthritis. The 1/22/2023 admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. The MDS documented that the resident frequently had pain, pain affected daily function, and the worst pain over the previous 5 days was 10 on a scale of 0-10, with 10 being the worst pain.
A Comprehensive Care Plan (CCP) effective 1/20/2023 titled Pain Management-Acute Pain, documented the resident had pain related to Chronic Pain Syndrome. Interventions added to the care plan on 2/2/2023 included to administer medications per physician orders; ongoing assessment of the resident's pain with emphasis on the onset, location, description, intensity of pain, and alleviating and aggravating factors; and to monitor side effects and adverse reactions resulting from the interventions rendered.
The physician's orders dated 1/20/2023 documented the following:
Administer Oxycodone, 5 milligram (mg) tablet, give one tablet every 6 hours as needed (PRN) for pain.
Administer Naproxen 500 mg tablet, give 1 tablet every 12 hours as needed (PRN) for pain.
Administer Gabapentin 800 mg tablet, give 1 tablet every 8 hours for Idiopathic Peripheral Autonomic Neuropathy.
Administer Acetaminophen 325 mg tablet, give two tablets (650 mg) every 6 hours as needed (PRN) for pain.
Administer Pregabalin 100 mg capsule, give 1 capsule three times a day for Idiopathic Peripheral Autonomic Neuropathy.
Review of the January 2023 Medication Administration Record (MAR) revealed the following:
The PRN (as needed) 5 mg Oxycodone was given every day in January since admission on [DATE] with inconsistent pain monitoring. On 1/20/2023 at 5:54 PM and 11:55 PM; 1/21/2023 at 8:38 AM; 4:31 PM, and 11:27 PM; 1/22/2023 5:55 AM and 6:10 PM; and 1/23/2023 12:31 AM and 10:01 AM; 1/24/2023 at 12:55 AM there was no there was no pain monitoring prior to and after the administration of the medication.
The following was documented for other oxycodone administrations: On 1/25/2023 at 8:57 AM the pain was assessed as 6 out of 10; however there was no assessment after the medication administration. On 1/26/2023 at 4:57 PM the pain was assessed at 10 out of 10 with a follow up of 7 out of 10 after the medication administration; On 1/27/2023 at 8:47 AM the pain assessment was documented as 6 out of 10 and there was no assessment post medication administration, at 5:05 PM the pain assessment was documented as 10 out of 10 and a follow-up pain assessment of 9 out of 10 after the medication was administered; and on 1/31/2023 at 1:39 AM the pain assessment documented pain level of 10 out of 10 with a follow up assessment with a pain level of 8 out of 10 after the medication administration, at 4:53 PM the pain level was documented as a 10 out of 10 with a follow up pain level of 9 out of 10 after the pain medication administration.
The MAR also revealed that Naproxen 500 mg was administered on 1/21/2023, 1/22/2023, 1/23/2023, 1/26/2023, 1/27/2023, and 1/31/2023 with no pain monitoring prior to and after the administration of the medication.
The MAR also revealed that Acetaminophen 325 mg, 2 tabs (650 mg) was administered on 1/22/2023 for pain level of 6 with no follow up; 1/25/2023 for pain of 6 with no follow up; 1/26/2023 for pain of 10 with follow up of 7; and 1/27/2023 for pain of 10 with follow up of 9 out of 10 after the pain medication administration
Resident #64 was interviewed on 1/31/2023 at 10:42 AM and stated they (Resident #64) have Neuropathy and Cellulitis of both lower legs. The best pain relief they (Resident #64) get is 5 out of 10 on their present medication regimen.
A Medication Administration Observation was conducted with Licensed Practical Nurse (LPN) #2 on 2/1/2023 at 9:39 AM. Resident #64 reported to LPN #2 that 5 mg of Oxycodone was not effective and was providing little pain relief. LPN # 2 stated they (LPN #2) would talk to the doctor right after the medication pass. The resident stated their (Resident # 64) pain level was 10/10 from their shoulders to their feet. The resident stated 5 mg of Oxycodone did not help, but the resident took the 5 mg oxycodone that was offered for now. The resident also stated the Acetaminophen was not effective.
Resident #64 was interviewed on 2/2/2023 at 8:50 AM. The resident stated there has been no other new pain control medication offered since reporting the pain control issues to LPN #2 yesterday on 2/1/2023. The resident stated no one came to see them after they told LPN #2 yesterday that the current pain medications were not relieving their pain.
Review of the medical record revealed no documentation that LPN #2 communicated the pain control concerns to the Nursing Supervisor or the physician.
LPN #2 was interviewed on 2/2/2023 at 8:53 AM and stated they (LPN #2) spoke to a Physician Assistant (PA #1) on 2/1/2023 and that PA #1 suggested alternating Acetaminophen with the Oxycodone. LPN #2 stated they (LPN #2) did not enter a progress note after talking to PA#1 on 2/1/2023 and should have.
A nursing progress note dated 2/2/2023 at 9:06 AM (entered as late), written by LPN #2, documented Resident #64 had pain level of 10/10 on 2/1/2023. The resident states their pain was from their shoulders to their feet. Oxycodone 5 mg given with positive effect. Resident stated the medication was not effective all the time. PA made aware with suggestion of alternating oxycodone and Tylenol for pain management.
PA #1 was interviewed on 2/2/2023 at 11:18 AM and stated that LPN #2 did not talk to them (PA #1) on 2/1/2023. PA #1 stated they (PA #1) were in the facility yesterday (2/1/2023) but did not see Resident #64 because the resident was not due to be seen and LPN #2 did not talk to them (PA #1) about this resident. PA #1 stated the resident should be seen by our pain management service. PA #1 stated the resident is on a significant amount of pain medications, but the pain medications can be adjusted for instance, the dosages and frequency, while we wait for pain management service.
A nursing progress dated 2/2/2023 at 1:00 PM, written by LPN #2, documented Resident #64 was complaining of pain from their arms to their feet. Oxycodone 5 mg was given with no effect. A new order was received for Oxycodone 10 mg every 6 hours as needed for pain.
A Physical Medicine and Rehabilitation (PMR) progress note dated 2/2/2023 documented increased pain, generalized in joints, recommend increasing Oxycodone to 10 mg every 6 hours.
The Director of Nursing Services (DNS) was interviewed on 2/3/2023 at 1:31 PM. The DNS stated if a resident is complaining of pain, the nurse should notify the PA, and if the PA is not around, then notify the Registered Nurse (RN) Supervisor who will do an assessment and notify the doctor. There should have been a progress note written on 2/1/2023 after the resident complained about pain to LPN #2.
RN #2 (Inservice Coordinator) was interviewed on 2/3/2023 at 2:47 PM. RN #2 stated if a resident is complaining of pain, the LPN should have reported the resident's pain to the RN Supervisor so an an assessment could be completed and the findings reported to the physician. RN #2 stated the nurse must document actions and conversations and follow up after a PRN medication is given to determine if the pain medication was effective.
10NYCRR 415.12

Based on observations, record review and interviews conducted during the Recertification Survey initiated on 1/31/2023 and completed on 2/7/2023, the facility did not ensure that each resident was free from significant medication errors. This was identified for one (Resident #271) of five residents reviewed for Unnecessary Medication. Specifically, Resident #271 had a Physician's order for Midodrine (medication used to treat low blood pressure) with Blood Pressure (BP) parameters to hold the medication if the systolic BP was greater than 110 Millimeters of Mercury (mmHg). The facility staff administered Midodrine on one occasion to Resident #271 when the medication was supposed to be held and held the medication twice when the medication was supposed to be administered.
The finding is:
The Policy and Procedure for Medication Administration: General Policies and Practices, dated March 2017 documented a resident's drug regimen must be free of unnecessary drugs. An unnecessary drug is any drug when used in: Excessive dose including a duplicate drug. The Staff nurse reviews the Electronic Medication Administration Record for accuracy after all medications for a specific resident have been prepared.
Resident # 271 was admitted with diagnoses including Orthostatic Hypotension (low blood pressure), Hypertension and Atrial Fibrillation. The Minimum Data Set (MDS) was not available due to the resident being a newly admitted resident at the facility.
The Physician's order dated 1/28/2023 documented to administer Midodrine 2.5 milligrams (mg) tablet, give 1 tablet (2.5 mg) by oral route every 8 hours, every day at 10:00 PM; 2:00 PM; 6:00 AM, and monitor blood pressure (BP) and hold the medication if the Systolic BP (SBP) is greater than (>) 100 millimeters of Mercury (mmHg).
The Physician order dated 1/30/2023 for Midodrine was changed to administer Midodrine 2.5 mg tablet, give 1 tablet (2.5 mg) by oral route every 8 hours every day at 10:00 PM; 2:00 PM; 6:00 AM. HOLD FOR SBP > (greater than) 110 mmHg Protocol:
HOLD SBP < (less than) 110 mmHg for Orthostatic Hypotension. This order was entered by Licensed Practical Nurse (LPN) # 6 on 1/30/2023 at 9:51 AM.
The Physician order dated 2/01/2023 at 6:53 AM documented to administer Midodrine 2.5 mg tablet, give 1 tablet (2.5 mg) by oral route every 8 hours. HOLD FOR SBP > (greater than)110 mmHg every day at 10:00 PM; 2:00 PM; 6:00 AM.
The January 2023 Medication Administration Record (MAR) documented on 1/30/2023 Midodrine 2.5 mg, give 1 tablet (2.5 mg) by oral route every 8 hours HOLD FOR SBP > (greater than) 110 mmHg. Protocol: HOLD SBP < (less than) 110 mmHg for Orthostatic Hypotension and Monitor blood pressure, Start Date: 1/30/2023. On 1/31/2023, Midodrine was held at 6 AM with a Blood Pressure (BP) reading of 96/60 mmHg and on 1/31/2023, Midodrine was administered at 10 PM with a BP reading of 117/81 mmHg.
Review February 2023 MAR documented Midodrine 2.5 mg tablet, give 1 tablet (2.5 mg) by oral route every 8 hours HOLD FOR SBP > (greater than)110 mmHg. Protocol: hold for SBP > (greater than)110 mmHg. On 2/2/2023 at 6 AM, the medication was held with a BP reading of 94/58 mmHg.
The package insert for Midodrine medication documented a warning: Supine Hypertension: The most potentially serious adverse reaction associated with Midodrine hydrochloride therapy is marked elevation of supine arterial blood pressure (supine hypertension). It is essential to monitor supine and sitting blood pressures in patients maintained on Midodrine hydrochloride. Uncontrolled hypertension increases the risk of cardiovascular events, particularly stroke. The package insert also documented that the supine and standing blood pressure should be monitored regularly, and the administration of Midodrine Hydrochloride Tablets, USP should be stopped if supine blood pressure increases excessively.
LPN# 6 was interviewed on 2/2/2023 at 2:10 PM and stated the directions entered into the computer were an input error and should have read to hold if the SBP was over 110 mmHg as per the Physician's order.
The Director of Nursing Services (DNS) was interviewed on 2/7/2023 at 2:25 PM and stated there was an input error for the medication Midodrine. The DNS stated that it is also the responsibility of the Medication Nurses to know the medications. If the directions were not clear, the medication nurse should have questioned the directions. Medication nurses should check the medication orders for accuracy prior to administration.
The Physician Assistant #2 was interviewed on 2/7/2023 at 2:35 PM and stated Midodrine is given for Hypotension and nurses should hold the medication when the SBP was above 110 mmHg. The Electronic Medical Record (EMR) has standardized parameter protocols for BP medications and the nurses should check the parameters and that the directions are correct when they (nurses) are entering the BP medication orders in the EMR. After this medication error was identified, the facility is making sure the nurses write out greater and less than instead of using the symbols.
10NYCRR 415.12(m)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the Recertification Survey initiated on 1/31/2023 and completed on 2/7/2023, the facility did not ensure that admission and Annual Minimum Data Set (MDS) assessments were completed within 14 calendar days after admission and not less than once every 12 months for 13 (Resident #4, #9, #22, #26, #59, #71, #73, #86, #94, #95, #98, #106, and #107) of 19 residents reviewed for Resident Assessment. Specifically, three (Resident #86, #106 and #107) of 19 Residents did not have an admission MDS completed within 14 calendar days of admission and 10 (Resident #4, #22, #26, #59, #71, #73, #94, #95, and #98) of 19 had an Annual MDS assessment completed less than once every 12 months. Additionally, the facility provided a report titled Overdue MDS, which revealed that 18 admission and 6 Annual MDS Assessments were not completed as of 2/2/23 which included two (Resident #9 and 71) of 19 Residents reviewed for Resident Assessments.
The findings include but are not limited to:
The Facility MDS 3.0 Completion policy dated 4/2008 documented that the facility will utilize the Center for Medicare and Medicaid (CMS) Minimum Data Set (MDS) 3.0 for resident assessment. The MDS required data elements are transmitted to New York State according to CMS requirements. The MDS assessment, which will be used to develop the resident's Comprehensive Care Plan (CCP), will be completed at the time of admission, whenever there is a significant change, and at least quarterly. The admission (Initial) assessment (Comprehensive) MDS must be completed by the 14 th calendar day of the resident's stay, may be combined with the discharge assessment as indicated. The Annual (Comprehensive) MDS must be completed within 366 calendar days of the Assessment Reference Date (ARD) of the last comprehensive assessment.
The facility report entitled, Overdue MDS dated 2/2/2023 documented 103 MDS assessments were overdue facility wide. The report indicated that Residents #9 and #71 had an overdue Annual MDS assessment.
-Resident #9's Annual MDS assessment dated [DATE] was not completed as of 2/2/2023.
-Resident #71's Annual MDS assessment dated [DATE] was not completed as of 2/2/2023.
The Overdue MDS report also documented Resident #106's admission MDS assessment with an assessment reference date of 9/1/2022 was not completed until 11/7/2022.
The MDS Coordinator was interviewed on 2/2/2023 at 1:22 PM. The MDS Coordinator stated that they (MDS Coordinator) have been the MDS Coordinator since October 2021. The MDS Coordinator stated that they were the only person completing MDS's for the whole facility. In early September 2022, the MDS Coordinator informed the Director of Nursing Services (DNS) that they were falling behind on their work and MDS assessments were not completed on time. The DNS hired a part-time MDS Coordinator mid-September 2022 to assist with catching up on the MDS assessments. The Part-time MDS Coordinator works 3 days a week. The MDS Coordinator stated that even with the part- time MDS Coordinator they are still behind and are still catching up. The MDS Coordinator stated that they reviewed the medical records for Resident #4, #9, #22, #25, #26, #48, #55, #59, #61, #71 #73, #79, #86, #90, #94, #95, #98, #106, and #107 on 2/1/2023 and their MDS assessments were not yet completed. The MDS Coordinator stated that there was a mix of Annual, Quarterly, Death entries MDS assessments due for all 19 residents. The MDS Coordinator stated that they began to work on the list of 19 residents brought to their attention and are in the process of completing their MDS assessments.
The DNS was interviewed on 2/2/2023 at 1:41 PM. The DNS stated that they (DNS) were made aware that the MDS Coordinator was behind on MDS assessments in September 2022. The DNS stated that when the MDS Coordinator showed them a report of overdue MDS's in September 2022, there were about 300 outstanding MDS assessments. The DNS hired a part-time MDS Coordinator 3 days a week to assist in response to the MDS Coordinator's report. The DNS stated that they have a case manager who started to organize the care plan meetings and morning report meeting to free up the MDS Coordinator to work on the over-due MDS assessments. The DNS stated that in another week or two, they expect the facility to be caught up. The DNS stated that the facility just did a submission of MDS assessments that were completed in December 2022.
The DNS was re-interviewed on 2/3/2022 at 2:24 PM. The DNS stated that the part-time MDS Coordinator was hired on 9/20/22. The DNS provided a report entitled Overdue MDS dated 2/2/2023. The DNS stated that they reviewed the overdue and incomplete MDS assessments, and the facility was currently behind on 103 MDS assessments as of 2/2/2023.
The DNS was re-interviewed on 2/6/2023 at 9:42 AM and stated that the completion of Annual and admission MDS assessments are due 14 days from the assessment reference date and the care plan completion is 7 days from the MDS completion date. The transmission to CMS is no later than 14 days the care plan completion date or 35 days from the assessment reference date. The DNS stated that the Unit Managers complete the care plan assessments and organize the care plan meetings within the 21 days of the assessment date. The Unit Managers complete the care plans by reviewing the medical records and their assessments on the units. The MDS Coordinator then reviews the data and completes the MDS assessments after the Unit Managers complete their assessments. The DNS stated that the Unit Managers are not directly involved in the MDS completion. The DNS stated that they are looking to hire full time MDS Coordinators and have placed job openings online to recruit. The DNS stated that they (DNS) are having a hard time finding an MDS Coordinator.
The Administrator was interviewed on 2/6/2023 at 10:50 AM. The Administrator stated that the DNS informed them (Administrator) that the MDS Coordinator was behind in September 2022. The Administrator stated that they responded to the problem by hiring a part-time MDS Coordinator. The Administrator stated that they (Administrator) did an MDS submission in December 2022 and received a validation report with a message which indicated that the facility was overdue by way too many MDS's; however, the Administrator could not recall an exact number. The Administrator was not aware it was that bad in September 2022. The Administrator stated that the facility ensured that care plans were completed by the Unit Managers so care plan completion was not affected by the overdue MDS assessments. The Administrator stated that they reviewed the report of 103 overdue MDS assessments and they expect to have the assessments to be completed with the help of the part-time MDS Coordinator. The part-time MDS Coordinator needed some time to learn the electronic medical record system in September 2022, so they were not able to quickly assist with catching up on the MDS assessments. The Administrator decided that the facility had to place an advertisement to get two more full time MDS Coordinators. The Administrator further stated that they believe it would be best to have MDS Coordinators assigned to the units and solely focus on the care plans and the MDS completion.
10NYCRR 415.11(a)(3)(i)

Based on observation, record review, and staff interviews during the Recertification Survey initiated on 1/31/2023 and completed on 2/7/2023 the facility did not ensure that an infection prevention and control program was established to maintain a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #272) of four residents observed for medication administration. Specifically, during the medication pass observation, Licensed Practical Nurse (LPN) #1, the medication nurse, did not wear appropriate Personal Protective Equipment (PPE) while administering medications for Resident #272, who was on contact and droplet precautions for Respiratory Syncytial Virus (RSV), and was observed coughing. Additionally, LPN #1 did not appropriately remove their PPE before exiting the resident's room when the medication administration was completed.
The finding is:
The facility's policy titled Control of Communicable Disease-RSV (Respiratory Syncytial Virus) revised 9/2022, documented RSV is spread through contact with droplets from the nose and throat of infected people when they cough and sneeze. Utilize proper personal protective equipment (PPE) for contact and droplet precautions. Upon entry to the room all staff must don the following PPE (gown, gloves, mask, and eye protection) and prior to exit all PPE must be doffed (taken off).
Resident #272 was admitted with diagnoses including Hip Fracture, Heart Failure, and Hypertension. The 1/17/2023 admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact.
A physician's order dated 1/30/2023 documented to maintain Droplet and Contact precautions/isolation every shift for positive RSV infection.
A nursing progress note dated 1/30/2023 at 11:12 AM documented the resident's cough increasing with an audible wheeze. The physician assistant (PA) was made aware and new orders for a respiratory panel were obtained.
A nursing progress note dated 1/30/2023 at 1:28 PM documented that a call was received from the laboratory. Resident #272 was positive for RSV. The isolation protocol was in place.
During an observation on 2/1/2023 at 9:13 AM LPN #1 performed medication administration for Resident #272. The resident's room door had signs indicating the room was on contact and droplet precautions. The droplet precaution sign documented everyone must make sure their eyes, nose, and mouth are fully covered before room entry (illustration included either a face shield or goggles). The sign documented to remove face protection before room exit. After LPN #1 prepared the resident's medications, they (LPN #1) donned a gown and gloves. LPN #1 was wearing an N95 mask (there was no surgical mask covering the N95). LPN #1 did not put on a face shield or goggles. LPN #1 then entered the room and provided the medications to Resident #272, who was sitting in a wheelchair. The resident was not wearing a mask and was observed coughing. After LPN #1 administered the medications, they (LPN #1) removed their gown and gloves and sanitized their hands. The nurse did not remove and change the N95 mask before exiting the resident's room.
LPN #1 was interviewed on 2/1/2023 at 9:20 AM after LPN #1 exited Resident #272's room. LPN #1 stated they (LPN #1) do not wear goggles or face shield when working with RSV residents and do not change the N95 face mask after working with RSV residents. LPN #1 stated they would wear a face shield or goggles and change the N95 only if the resident was COVID-19 positive. LPN #1 then proceeded to another resident's room.
Registered Nurse (RN) #1, who was the Assistant Director of Nursing Services (ADNS) and the Infection Preventionist (IP), was interviewed on 2/2/2023 at 8:30 AM. RN #1 stated that RSV infection spreads the same way as COVID-19 infection through droplets and direct contact. Residents who are diagnosed with RSV infection are required to be placed on contact and droplet precautions. RN #1 stated staff must wear goggles or a face shield when caring for RSV-infected residents and that LPN #1 should have changed the N95 mask if it was not covered by a surgical mask because of the potential for contamination from the RSV droplets.
RN #2, the Inservice Coordinator, was interviewed on 2/2/2023 at 2:08 PM. RN #2 stated RSV infection spreads like COVID-19. RN #2 stated LPN #1 should have been wearing goggles and should have changed their N95 mask.
The Director of Nursing Services (DNS) was interviewed on 2/3/2023 at 1:30 PM. The DNS stated that droplet precautions do not just apply to COVID-19; RSV infection spread is similar to COVID-19. The DNS stated LPN #1 should have worn facial protection when administering the medications. The DNS further stated that LPN #1 should have changed the N95 mask after completing the medication pass because the N95 mask was not covered by a surgical mask and was considered potentially contaminated.
10NYCRR 415.19(a)(1-3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the Recertification Survey initiated on [DATE] and completed on [DATE], the facility did not ensure that Quarterly Minimum Data Set (MDS) assessments specified by the state and approved by the Center for Medicare and Medicaid Services (CMS) were completed not less frequently than once every 3 months for 19 (Resident #4, #9, #22, #25, #26, #48, #55, #59, #61, #71 #73, #79, #86, #90, #94, #95, #98, #106, and #107) of 19 residents reviewed for Resident Assessment. Specifically, the facility did not complete Quarterly Minimum Data Set Assessments at least every 92 days following the previous assessment for all 19 Residents sampled for Resident Assessment. Additionally, the facility provided a report titled Overdue MDS, which revealed that 28 Quarterly MDS Assessments were not completed as of [DATE] which included 6 (Res #55, #59, #61, #71, #95 and #98) of 19 Residents reviewed for Resident Assessments.
The finding is but not limited to:
The Facility MDS 3.0 Completion policy dated 4/2008 documented that the facility will utilize the Center for Medicare and Medicaid (CMS) Minimum Data Set (MDS) 3.0 for resident assessment. The MDS required data elements are transmitted to New York State according to CMS requirements. The MDS assessment, which will be used to develop the resident's Comprehensive Care Plan (CCP), will be completed at the time of admission, whenever there is a significant change, and at least quarterly. Quarterly Assessment reference date of the previous assessment of any type + (plus) 92 calendar days at maximum.
The facility report entitled Overdue MDS dated [DATE] documented 103 MDS assessments were overdue facility wide. The report indicated Resident #55, #59, #61, #71, #95 and #98 had an overdue Quarterly MDS. Examples include but are not limited to:
-Resident #55's Quarterly MDS dated [DATE] was not completed as of [DATE].
-Resident #61's Quarterly MDS dated [DATE] was not completed as of [DATE].
-Resident #90's Quarterly MDS with the assessment reference date of [DATE] was not completed until [DATE]. Resident #90 expired on [DATE] and Resident #90's Death in Facility Tracking Record dated [DATE] was not completed until [DATE].
The MDS Coordinator was interviewed on [DATE] at 1:22 PM. The MDS Coordinator stated that they (MDS Coordinator) have been the MDS Coordinator since October of 2021. The MDS Coordinator stated that they were the only person doing MDS's for the whole facility. In early [DATE], the MDS Coordinator informed the Director of Nursing Services (DNS) that they were falling behind on their work and MDS' were not completed on time. The DNS hired a part-time MDS Coordinator mid-[DATE] to assist with catching up on the MDS assessments. The part-time MDS Coordinator works 3 days a week. The MDS Coordinator stated that even with the part-time MDS Coordinator they are still behind and are catching up. The MDS Coordinator stated that they reviewed the medical records for Resident #4, #9, #22, #25, #26, #48, #55, #59, #61, #71 #73, #79, #86, #90, #94, #95, #98, #106, and #107 on [DATE] and their MDS assessments were not completed yet. The MDS Coordinator stated that they began to work on the list of 19 residents brought to their attention and are in the process of completing their MDS assessments.
The DNS was interviewed on [DATE] at 1:41 PM. The DNS stated that they (DNS) were made aware that the MDS Coordinator was behind on MDS's in [DATE]. The DNS stated that they could not recall the exact date and it was within two weeks of hiring the part-time MDS Coordinator to assist. The DNS stated that when the MDS Coordinator showed them a report of overdue MDS's in [DATE], there were about 300 outstanding MDS assessments. The DNS hired a part-time MDS Coordinator 3 days a week to assist in response to the MDS Coordinator's report. The DNS stated that they have a case manager who started to organize the care plan meetings and morning report meeting to free up the MDS Coordinator to work on the over-due MDS assessments.
The DNS was re-interviewed on [DATE] at 2:24 PM. The DNS stated that the part-time MDS Coordinator was hired on [DATE]. The DNS provided a report entitled Overdue MDS dated [DATE]. The DNS stated that they reviewed the overdue and incomplete MDS report, and the facility was currently behind on 103 MDS assessments as of [DATE].
In a subsequent interview with the DNS on [DATE] at 9:42 AM the DNS stated that the completion of the Annual and admission MDS assessments are due 14 days from the assessment reference date (ARD) and the care plan completion is 7 days from the MDS completion date. The transmission of the MDS assessments to CMS is no later than 14 days of the care plan completion date or 35 days from the assessment reference date. The DNS stated that the Unit Managers complete the care plan assessments and organize the care plan meetings within the 21 days of the assessment date. The Unit Managers complete the care plans by reviewing the medical records and their assessments on the units. The MDS Coordinator then reviews the data and completes the MDS after the Unit Managers complete their assessments. The DNS stated that they are looking to hire full time MDS Coordinators and have placed job openings online to recruit. The DNS stated that they (DNS) are having a hard time finding an MDS Coordinator.
The Administrator was interviewed on [DATE] at 10:50 AM. The Administrator stated that the DNS informed them (Administrator) that the MDS Coordinator was behind in [DATE]. The Administrator stated that they responded to the problem by hiring a part-time MDS Coordinator. The Administrator stated that they (Administrator) did an MDS submission in [DATE] and received a validation report with a message which indicated that the facility was overdue by way too many MDS's; however, could not recall an exact number. The Administrator stated that the facility ensured that care plans were completed by the Unit Managers so care plan completion was not affected by the overdue MDS assessments. The Administrator stated that they reviewed the report of 103 overdue MDS assessments and expected to have the assessment completed with the help of the part-time MDS Coordinator. The part-time MDS Coordinator needed some time to learn the electronic medical record system in [DATE], so they were not able to quickly assist with catching up on MDS assessments. The Administrator decided that the facility had to place an advertisement to hire two more full-time MDS coordinators. The Administrator further stated that they believe it would be best to have MDS Coordinators assigned to the units and solely focus on the care plans and the MDS completion.
10 NYCRR 415.11(a)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey, the facility did not ensure that residents receive treatment and care in accordance with professional standards and the comprehensive person-centered care plan. This was identified for one (Resident #13) of two residents reviewed for dignity and one (Resident #99) of one resident reviewed for skin condition. Specifically, 1) Resident #13 had an order for Silvadene 1% topical cream which was initiated for a buttocks rash. There was no documented evidence that an assessment of the change in the resident's skin condition was completed by a Registered Nurse (RN) or a Physician and there was no documented evidence that a Comprehensive Care Plan (CCP) was developed for the change in the resident's skin condition; and 2) Resident #99 was identified with a large area of discoloration to the inner upper right arm. The medical record lacked documented evidence that the Physician was notified of the discoloration, or that the area of discoloration was assessed by an RN.
The findings are:
1) Resident #13 was admitted to the facility with diagnoses including Hemiplegia/Hemiparesis and Pathological Fracture of the Left Femur. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) Score of 15 which indicated intact cognition. The resident had no behavior symptoms, and required extensive assist of one staff member for transfers, toileting, and personal hygiene.
A Treatment Administration Record (TAR) dated 2/2020 documented on 2/23/2020, Silvadene 1% topical cream, apply by topical route. The TAR documented to cleanse the buttocks with soap and water and to apply cream for Skin Eruption.
The Progress notes dated 2/10/2020 to 2/24/2020 were reviewed on 2/24/2020 at 11:30 AM. There was no documented evidence of an assessment regarding the excoriation to the resident's buttocks.
The resident's CCP was reviewed on 2/24/2020 at 11:30 AM and there was no documented evidence of a CCP developed for impaired skin.
A CCP for skin integrity dated 2/24/2020 documented the resident had an excoriation to the buttock area. Interventions including to assess the skin every shift and to provide treatment as ordered.
The resident was observed on 2/24/2020 at 10:05 AM with the RN Unit Manager. Three medication cups containing a white cream were observed on the sink counter in the resident's room. The RN stated the cream was Silvadene and that the Silvadene cream should not have been left in the resident's room. The RN further stated the Silvadene was a Physician's order that was to be administered by the nurse.
The Licensed Practical Nurse (LPN) was interviewed on 2/24/2020 at 10:15 AM. The LPN stated the resident receives Silvadene treatment to her buttocks and the treatment is to be applied by the nurse and was not to be left in the resident's room. The LPN stated that she had not done the treatment for the 7-3 shift as yet and that she did not leave the cream in the resident's room. During the interview the LPN asked the resident who had left the cups containing the cream on the sink. The resident wrote on her clipboard that the night nurse had left the cream in her room. A fourth cup of cream was observed in the drawer of the resident's night table. The LPN stated the cream was left for the CNA to apply after providing care.
The 7:00 AM - 3:00 PM Certified Nursing Assistant (CNA) was interviewed on 2/24/2020 at 10:30 AM. The CNA stated that most of the time she used A and D ointment on the resident after providing peri-care. The CNA stated that if she was performing AM care the nurse would bring the Silvadene cream at that time and she (the CNA) would apply the cream to the resident's buttocks.
The Director of Nursing Services (DNS) was interviewed on 2/24/2020 at 1:42 PM. The DNS stated that creams ordered for treatment should not be left at the bed side. The DNS stated when there was a change in the resident's skin condition the RN should be notified, and an assessment of the area should be completed. Additionally, the DNS stated the RN should have notified the Physician, obtained a treatment order if warranted, and documented her assessment in a progress note. The DNS further stated that a CCP should have been initiated or updated.
The Nurse Practitioner (NP) was interviewed on 2/24/2020 at 2:55 PM. The NP stated today, 2/24/2020, he received a call for an order for Silvadene. The NP stated he expected to be notified by the nursing staff when there was a change in the resident's skin condition to obtain an order for treatment. The NP further stated that he examined the resident today and the resident was assessed to have an excoriation on the buttocks.
2) Resident #99 was admitted to the facility with diagnoses including Chronic Atrial Fibrillation and Coronary Artery Disease. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) Score was 14 which indicated the resident was cognitively intact. The resident had no behavior problems and required extensive assist of one staff member for bed mobility and transfers. The resident required set up help only for locomotion on and off the unit.
The resident was observed on 2/18/2020 at 3:05 PM. A large bruised area was observed to the right upper inner arm. The resident stated that he was receiving blood thinners.
A Comprehensive Care Plan (CCP) for Skin Integrity dated 1/3/2020 documented the resident was at high risk for skin breakdown related to decreased mobility, incontinence, edema, anemia, or malnourishment. Interventions included Certified Nursing Assistant (CNA) evaluation of the resident's skin condition daily during care and to report any skin abnormalities to the nurse.
A CCP for Anticoagulant Therapy dated 11/12/19 documented interventions that included to: administer anticoagulant therapy as per the MD order, assess for signs and symptoms of bleeding, avoid bumping, handle the resident gently when providing hands on care, report any changes in skin condition (ecchymosis/discoloration), report signs of abnormal bleeding or side effects of medication to the physician, and to perform skin checks every shift.
A Physician's order dated 10/11/19 documented Eliquis 5 milligram (mg) 1 tablet by mouth (po) every 12 hours for Atrial Fibrillation and Aspirin 81 mg 1 tablet by po for Coronary Artery Disease.
Resident #99 was interviewed on 2/24/2020 at 10:20 AM. The resident stated that he uses the upper side rails to pull himself up in bed and that he bumps his arm on the side rail during the process. The resident stated that he told the LPN that he bumps his arm on the side rail when he pulls himself up in bed using the side rails.
The CNA was interviewed immediately on 2/24/2020 at 10:22 AM and stated that she could not recall the date; however, the CNA stated that she saw the discoloration last week and reported the discoloration to the Licensed Practical Nurse (LPN) medication nurse.
The LPN medication nurse was interviewed on 2/24/2020 at 10:24 AM. The LPN stated she was informed by the CNA that there was an area of discoloration to the resident's upper right arm. The LPN stated the resident mentioned the area to her and that she reported the discoloration to the Registered Nurse (RN) Manager and the Physician. The LPN further stated that she did not document the area of discoloration in the progress note and should have.
The RN Manager was interviewed on 2/24/2020 at 10:40 AM. The RN Manager stated she was made aware of the area of discoloration but did not assess the area. The RN Manager stated that she should have assessed the area when she was notified, initiated interventions as needed, and documented her assessment in the progress note. Additionally, the RN Manager stated that she will complete an assessment and initiate padding for the side rail.
The Nurse Practitioner (NP) was interviewed on 2/24/2020 at 3:02 PM. The NP stated that he was notified today, 2/24/2020, of the discoloration to the resident's right upper arm.
415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews during the Recertification survey, the facility did not ensure that each resident had a person-centered Comprehensive Care Plan (CCP) developed to address the resident's medical and nursing needs. This was identified for two (Resident #134 and Resident #77) of two residents reviewed for restraints. Specifically,1) Resident #134 did not have a CCP developed for the use of a bed alarm; and 2) Resident # 77 did not have a CCP developed for the use of a chair alarm.
The findings are:
1) Resident #134 has diagnoses including Dementia and Pneumonia. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] did not document the use of alarms in the Restraints and Alarms section of the MDS. An Annual MDS dated [DATE] documented the use of a bed alarm restraint.
A Physician's order dated 10/14/19 documented a bed alarm when in bed.
The Resident Care Profile, which provides direction to the Certified Nursing Assistants (CNA) for resident care needs, from October 2019 to February 2020 documented the use of a bed alarm and daily checks for placement and functioning.
The medical record was reviewed, including the CCPs, since 5/24/19 and there was no documented CCP for the use of the bed alarm.
The Director of Nursing Services (DNS) was interviewed on 2/21/20 and stated he would develop a CCP for the use of the bed alarm.
The DNS was re-interviewed on 2/24/20 at 9:44 AM. The DNS stated that a CCP for the bed alarm was not initiated until 2/21/20; however, the Resident Care Profile documented the use of the bed alarm when first ordered on 5/23/19. He stated that the unit Registered Nurse (RN) managers are responsible to initiate the CCPs. He stated that the resident was on unit E and was moved to unit C on 7/18/19. The DNS further stated that the C unit RN Manager does not work here any more and the E unit RN manager started working here only two months ago.
The C unit RN manager was interviewed on 2/24/20 at 10:00 AM and was not aware that there was not a CCP developed for the use of the bed alarm. She stated that the team last reviewed the CCPs in a meeting held on 2/10/20.
The MDS Coordinator was interviewed on 2/24/20 at 10:32 AM. She stated the bed alarm should have been documented in the MDS dated [DATE]. She also stated that the CCP team should have identified that there was no bed alarm CCP in place during the CCP meeting held for the resident on 2/10/20.
2) Resident #77 has diagnoses including Dementia, Major Depressive Disorder, and Arthritis. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 5 indicating the resident had severely impaired cognition. The MDS documented that a chair alarm was used daily.
Resident #77 was observed on 2/19/2020 at 8:01 AM with a chair alarm in place.
The Physician's order dated 2/20/2020 documented to check the chair alarm for placement and functionality each shift.
A Certified Nursing Assistant (CNA) profile record dated 2/2020 documented to place a chair alarm on the resident's wheel chair.
There was no documented evidence a CCP was developed for the use of the chair alarm.
An interview was held with the Registered Nurse (RN) MDS Coordinator on 2/24/20 at 11:00 AM. The RN stated a CCP was not developed for the use of the chair alarm.
An interview was held with the Assistant Director of Nursing (ADNS) on 2/24/2020 at 11:15 AM. The ADNS reviewed the CCPs and stated there was no CCP developed for the use of the chair alarm.
An interview was held with the RN unit manager on 2/24/2020 at 2:00 PM. The RN stated a CCP was not developed. The RN stated they were not aware that a chair alarm required a CCP.
415.11(c)(1)